Alberta Health Care Insurance Plan

AHCIPClaim Submission Seminar

New Members

Jeffrey P Schaefer, MD

July 14, 2010

Objective

• Know the anatomy of an AHCIP claim• Know the common situations

1. Comprehensive Consultation

2. Minor and Repeat Consultation

3. Hospital Visits

4. Emergency Detention

5. After Hours Time Premiums

6. Conferences

7. Office Visits

8. Telephone Consultations

9. Telephone Calls from Allied Health Care

billing.healthlearner.com

• Sources of Truth– Medical Governing Rules– Medical Benefits Procedure List– Medical Benefits Price List– Fee Modifier Definitions– Explanatory Code List

http://www.health.alberta.ca/professionals/somb.html http://www.health.alberta.ca/professionals/fees.html

Elements of an AHW Claim• Demographics

– AHCIP AHW requires the PHN only– OOP requires everything– College requires complete billing records

• Location– Facility and Functional Centre

• Diagnosis Code– ICD-9

• Referring Physician– PRACID if in Alberta (not required otherwise)

• Health Service Code– implicit modifier– explicit modifier

HSC and Modifiers

• HSC Health Service Code

– refers to the service rendered

– 03.08A comprehensive consultation– 03.03D hospital visit– 03.03F office / clinic visit– 02.82A transesophageal echocardiogram– 03.01AA providing care in hospital after hrs

Modifiers• Modifiers:

• changes the value of the service• changes the rules for claiming the service

– Implicit Modifier• pre-entered or derived by the Claim Submitter

– Explicit Modifiers• must be entered with each claim (you write this in)• up to 3 with any HSC may be submitted

Implicit Modifier Categoriesprogrammed into the billing software

establish your SKLL code (once)

• LEVL (level)– INMDH1, INMDH2…

• SKLL– INMD

• AGE– G75 e.g. 03.03A

Relevant Explicit Modifier Categoriesphysician must supply these

• CARE (complex patient care)– COMX, CMXC30, CMXV15, CMXV20

• SURC (services unscheduled)– EV, NTPM, NTAM, WK

• SURT (after hours premium: 03.01AA)– TEV, TNTP, TNTA, TWK, TST

• TELE (telehealth)– TELES

• There are several others relating mostly to procedures…

Comprehensive Consultation

• HSC = 03.08A– Possible Explicit Modifiers:

• SURC: EV or NTPM or NTPM or WKTEV• CARE: CMXC30• TELE: TELES

• Rules about consultations…• 1 per 180 days per patient• AHW and College rules apply

Procedures List

Price List

Possible Surcharges for the 03.08A(from the Price List)

Minor Consultation orRepeat Consultation (< 180 d)

(same price)

Comprehensive Geriatric Assessment

03.08A + CMXC30 + 03.08I vs 03.04K1.5 hours is break point

less 03.08A more 03.04K

• 2 hour consultation– 03.08A + CMXC30 $183.86 + $28.70– 03.08I x 4 (max) 42.94/15min = $171.76

Total = $384.32

– 03.04K + COMGER $300 + (2 x $50) – Total = $400

Hospital Visits• 03.03D . . . . . . . . . . . . . . . . . . . $51.25

– Hospital Visit– Modifier: COMX (20 minutes) add $36.90

CARE (COMX)$36.90

Transfers of Care• 03.03D + TOC

• 03.03AO: hem, gim, medonc, endo…

Emergency Detention per 15 minbedside attendance

• needs supporting text… e.g. patient in respiratory failure / distress.

• After Hours Time Premium 03.01AA– this is a Health Service Code– hospital care provided outside of regular hours (08-17 M-F)– requires a SURT modifier (e.g. TEV, TNTP, TNTA, TWK, TST)– claim by the call (unit); each call is 15 min or portion thereof– claim must be for individual patients

Office / Clinic Visits• 03.03F

– Repeat office or scheduled outpatient visit in a regional facility, referred cases only

INMD: 15, 30, eligible

Prolonged Office Visit

Don’t forget the Modifiers!!!Office / Clinic Visit Modifiers

Office / Clinic Visit Modifiers

Physician to Physician Consultation• Referring Physician

– 03.01LG (M-F 7-17)

– 03.01LH (M-F 17-22, Sat-Sun 7-22)

– 03.01LI (22-7 anyday)

• Consultant– 03.01LJ (M-F 7-17)

– 03.01LK (M-F 17-22, Sat-Sun 7-22)

– 03.01LL (22-7 anyday)

– Lots of rules, not for expediting referrals <24h

Ref-d

Ref-ev/wk

Ref-a/p

Con-d

Con-ev/wk

Con-a/p

CallbacksTypically used for patients you attend on. Pays less than new or repeat consultation

• Inpatient Callbacks– 03.05N (M-F 0700 - 1700 hours)

– 03.05P (M-F 1700 - 2200 hours)

– 03.05QA (All 2200-2400 hours)

– 03.05QB (All 2400-0700 hours)

– 03.05R (Sat, Sun, Stat 0700-2200 hours)

d

ev

pm

am

wk

Callback Rules1. May only be claimed when a special call for

attendance is made on the patient's behalf.

2. The physician responds to such a call from outside the hospital, on an unscheduled basis.

3. The patient is attended on a priority basis.

4. There is direct attendance by the physician.

5. Second or subsequent patients seen during the same callback are not eligible for benefits under 03.05N, 03.05P, 03.05QA, 03.05QB or 03.05R but time spent may be claimed using the AFTER HOURS TIME PREMIUM modifier.

6. May not be claimed in association with any health service code except 03.01AA. Refer to GR 15.8

Callbacks and Emergency Visits:Emergency Depts, Outpatient Departments,

Auxillary Hospitals, Nursing Homes

• similar to inpatients

• billing.healthlearner.com

Family / Team Conference $42• Team Conference (per 15 min)

– 03.05JA

• Family Conference (per 15 min)– 03.05JB (?) or 03.05JC (Acute Care, In-pt)

• Palliative Care Family or Team (per 15)– 03.05T first call, 03.05U next calls

• Chronic Pain Team Conference– 03.05V first call, 03.05W next calls

• Chronic Pain Family Conference (/15 min)– 03.05X

Team Conference Family Conference

$42 / 15 min = typical of all

Team Conference Family Conference

$42 / 15 min = typical of all

Advice to Allied Health Care Workers

d

ev/wk

pm/am

Certification

Residents….

• Claims may be submitted by a physician who is present and supervising a resident or intern during the provision of a service.

ARP Codes• Codes paid at $0

• A couple might be useful…

Audits...

Diagnostic Codes• ICD-9 codes

• see billing.healthlearner.com

Category Codes

Summary• email me:

– codes you use– questions / concerns– tips